DKA And Hyperglycemic Hyperosmolar Flashcards
What are SIX precipitating factors of DKA/HHS?
Infection
New presentation of DM (usually kids w T1)
Insufficient insulin therapy
Pancreatitis
Acute CV events
Medications
What are some key signs and sx of DKA?
Quick onset (hrs-days)
Kussmaul breathing
acetone breath
N/V
Abdominal pain
(Shared: Hypothermia, tachycardia, altered mental, polydipsia, polyuria, weight loss)
What are some key signs and sx of HHS?
**slower onset (days-weeks)
Hypotension
(Shared: Hypothermia, tachycardia, altered mental, polydipsia, polyuria, weight loss)
What are some lab finding with DKA diagnosis?
BG >250
Acidosis
Low serum bicarb
(+) urine ketones
Anion gap >12
What are some lab finding with HHS diagnosis?
BG > 600
Serum osmolarity > 320mOsm/kg
Altered mental status
What is the ANION GAP equation?
Na - (Cl + HCO3)
Aka cations - anions
How do we correct for serum sodium in DKA/HHS?
+1.6 mEq Na for every 100mg BG over 100mg/dL
What is the serum osmolality equation?
2xNa + (glucose/18) + (BUN/2.8)
What are the three overarching steps to treating DKA/HSS?
- Hydration
- Correct hyperglycemia
- Fix electrolyte imbalances
When rehydrating DKA/HSS patients, what agents should we use? What if their chloride levels are too high?
Gold standard = NS
High chloride = use 1/2 NS
What are the steps to using insulin inpatient to correct hyperglycemia?
- 0.1 U/kg IV bolus + 0.1 U/kg/hr infusion
OR
0.14 U/kg/hr (no bolus) - Increase infusion rate each hour if BG doesn’t decrease by 50-75 mg/dL in hour 1
- Once BG 200-250 mg/dL (DKA) or 250-300 mg/dL (HHS) then decrease infusion to 0.05 U/kg/hr + add D5W until resolution
Normal potassium levels are 4-5 mEq/L. What do we do if the K+ <3.3?
Hold insulin and give 10-20 mEq/hr
Normal potassium levels are 4-5 mEq/L. What do we do if the K+ = 3.3-5.2?
Give 20-30 mEq K+ in each liter of fluid to maintain K+
Normal potassium levels are 4-5 mEq/L. What do we do if the K+ > 5.2?
Avoid giving any K+, check levels q2hrs
Why do we have to watch potassium levels in hyperglycemic emergencies?
Insulin therapy causes K+ to shift from extracellular space to intracellular, decreasing serum K+ availability
Bicarb administration during DKA/HSS has not been shown to improve outcomes, but when may it be considered?
If pH <6.9
D/C when venous pH >7.0
*note: may cause hypokalemia and increase risk of cerebral edema
What are the end point goals of DKA?
BG < 200 mg/dL AND 2 of the following:
- Bicarb ≥15 mEq/L
- pH > 7.3
- Anion gap ≤ 12 mEq/L
What are the end point goals of HHS?
Serum osmolality < 320 mOsm/kg
Recovery of mental status
What is the process when transitioning stabilized hyperglycemic pts to SQ insulin?
When crisis is resolved, pt is alert and able to eat
May resume home insulin regimen if appropriate (ie. Pt wasn’t adherent so crisis)
If starting new regimen = 0.4-0.5 U/kg/day with 40-50% as basal insulin
*when transitioning, overlap infusion and SQ insulin for ~2 hrs!
What are THREE complications of hyperglycemic crisis treatments?
Hypoglycemia
Hypokalemia
Cerebral edema (mostly in children w DKA)
What is euglycemic DKA? What is its presentation?
Uncommon complication associated with extreme fasting, surgery pregnancy and SGLT2i use
Presentation: normal BG + metabolic acidosis, lower bicarb levels and (+) urine ketones
How do you treat euglycemic DKA?
Same as normal DKA, but initiate D5W immediately to avoid hypoglycemia
